“If the Supreme Court overturns the individual mandate, the private health insurance market would likely weaken under the unbalanced weight of strict provisions to cover all those who seek insurance without the counterbalancing benefit of a new, largely healthy, population segment that would be provided under the mandate,” Moody’s said. “This scenario could become untenable for many insurers and hospitals, as costs would rise but revenues would not.”

There are additional challenges to non-profit hospitals in the ACA, specifically cuts in reimbursement rates for Medicare and reduction of funds paid to hospitals that serve a disproportionate share of Medicaid recipients, Moody’s said. “Removing the mandate would make the negative features of reform loom much larger.” Moody’s said the federal government could turn to a voucher system in which individuals would receive public help for them to buy health insurance, but the results for non-profits hospitals “would be more complex and hard to foresee.”

According to a recent poll, 55 percent of hospitals and health systems anticipate falling revenues as a result of the law, while 12 percent expect an increase. Twenty-eight percent were unsure of the law’s effect on revenue, indicating continued concern in the industry over the changes wrought by healthcare reform. Hospital executives agreed to give up $155 billion in government payments over 10 years in a deal to cap costs borne by the industry as a result of the ACA. The agreement followed a similar agreement with pharmaceutical companies and enabled the reform. Two crucial hospital groups — the American Hospital Association and the Federation of American Hospitals — backed the law. “Hospitals have acknowledged that significant healthcare savings can be achieved by improving efficiencies, realigning incentives to emphasize quality care instead of quantity of procedures,” Vice President Joe Biden said at the time. “Today’s announcement, I believe, represents the essential role hospitals play in making reform a reality.”

“Hospital and health systems’ financial health has a direct impact on the benefits offered to their employees,” said Maureen Cotter, a senior principal at HighRoads, which took the poll. “Even though 70 percent of those surveyed stated that they are committed to providing coverage in the long term, and no organizations have plans to discontinue coverage now or in the future, the coverage provided may take a new shape,” Cotter said.

There’s even more bad news in the fact that Howard Dean, a physician who formerly was chairman of the Democratic National Committee, a 2004 presidential candidate and governor of Vermont thinks that the high court will declare the mandate unconstitutional. Dean believes that Justice Anthony Kennedy’s swing vote will side with the conservative justices when it comes to the individual mandate. “I do believe that it’s likely the individual mandate will be declared unconstitutional. Kennedy will probably side with the four right-wing justices. The question is going to be, is this individual mandate question, can that be considered separately from the rest of the bill? And I think it will be.”

Dean also said the ACA can remain in place without the mandate. “It’s definitely not necessary for the bill to succeed,” Dean said. “It was mainly put in by academics who built the program for Governor Romney in Massachusetts, they had did it there, and for insurance companies who will benefit from extra customers.”

According to Dean, “The number of so-called free riders — people who will refuse to get insurance until they get sick — is going to be very, very small.” Dean noted that the actual benefit of the individual mandate is “relatively small. Everyone is a libertarian in America, whether Democratic, Republican or independent. They don’t like to be told what to do by government.”

The billion-dollar initiative will reward the “most compelling new ideas” for cutting costs and improving care of Medicare and Medicaid patients with rewarding federal grants. Called the Health Care Innovation Challenge, the initiative will provide between $1 million and $30 million over three years to individual organizations or coalitions that develop sustainable, new approaches to improving healthcare quality and efficiency. “We’ve taken incredible steps to reduce healthcare costs and improve care, but we can’t wait to do more,” said HHS Secretary Kathleen Sebelius. “Both public and private community organizations around the country are finding innovative solutions to improve our healthcare system, and the Health Care Innovation Challenge will help jump-start these efforts.”

This program is part of the Obama Administration’s “We Can’t Wait” initiative, which is a series of legal Executive Branch steps designed to move America forward while Congressional Republicans block critical and necessary legislation.

To demonstrate that its campaign to cut government waste is working, the White House said the administration cut improper payments by nearly $18 billion in 2011, largely in such programs as Medicare, Medicaid, Pell Grants and food stamps. Budget chief Jack Lew ordered federal agencies to tighten their oversight of contractors and grant recipients to reduce the potential for taxpayer waste.

Not surprisingly, there was some immediate opposition to the initiative, with Republican critics calling it a “$1 billion experiment.” “On the day the Supreme Court decided to review the constitutionality of ‘Obamacare,’ the president is asking for another $1 billion in taxpayer dollars to pay for another healthcare experiment that will continue taking us in the wrong direction,” said RNC spokeswoman Kirsten Kukowski. “We already spent $2.6 trillion on his job-killing health care bill. Another $1 billion Executive Order is just more words for a president more interested in campaign talking points than creating jobs.”

With the Supreme Court preparing to hear arguments for and against the Patient Protection and Affordable Care Act (ACA) next March, it is important to note that even the 26 states suing to have the law overturned are hedging their bets. Only four states have refused all federal money to plan for the changes that are scheduled to take place.

Several healthcare industry leaders expressed their support for the ACA. “The system is transforming itself,” said Charles N. Kahn III, president of the Federation of American Hospitals. “But the success of these changes depends a lot on whether there is sufficient funding.” Nationally, hospital systems are anticipating an influx of federal funds and patients as the law goes into full effect. “If the law is struck down, healthcare reform will have to continue one way or another,” said Patricia Brown, president of Johns Hopkins HealthCare.

A Congressional proposal to reform Medicare will transfer a significant share of the cost to the nation’s senior citizens – a constituency that is known for high voter turnout in elections. The Congressional Budget Office (CBO) added fodder for critics, concluding that the majority of future retirees would pay considerably more for healthcare under the “Path to Prosperity” approach — which turns Medicare into a voucher-like plan for Americans who are currently 54 and younger. Representative Paul Ryan

(R-WI), who introduced the plan, said “We don’t want to turn the safety net into a hammock that lulls people to lives of complacencies and dependencies, into a permanent condition where they never get on their feet.” Instead of coverage for a set of prescribed benefits, Americans in their mid-50s and younger would receive a federal payment to purchase private insurance from a choice of government-regulated plans. If the proposal becomes law, beginning in 2022, Americans would have a vastly different experience when they became eligible for Medicare. The age for eligibility would rise from 65 to 67, according to the CBO.

Ryan’s proposal slashes $1.4 trillion from Medicaidover the next decade. He proposes to cut $630 billion off the budget by more or less repealing the Patient Protection and Affordable Care Act’s provisions that extend coverage to include anyone living on less than 133 percent of the poverty rate — just under $30,000 for a family of four. Additionally, Ryan’s plan eliminates subsidies for private insurance premiums for those just above the poverty line. According to CBO estimates, nearly 17 million people without insurance would have been covered by the Medicaid expansion.

Representative Chris Van Hollen (D-MD), the ranking Budget Committee Democrat, said Republicans are protecting tax breaks for corporations and the wealthy to the detriment of the middle class and the poor. “It doesn’t reform Medicare, it deforms and dismantles it,” Van Hollen said. As for Medicaid, Ryan’s proposal “rips apart the safety net” for poor and older people. “A typical beneficiary would spend more for healthcare under the proposal,”according to the CBO analysis. “Although the uncertainty in future federal spending on healthcare would decrease under the proposal, that uncertainty would be transferred to future beneficiaries,” the CBO analysis said. “If the volume, complexity, and costs of medical services turned out to be greater than expected, future beneficiaries would pay higher premiums and cost-sharing amount than are currently projected.”

Ryan’s budget resolutionwould improve the nation’s overall fiscal health, cutting projected deficits in President Obama‘s budget and moving the federal government towards a surplus by 2040, according to the non-partisan CBO. Ryan believes that the cuts are necessary to save the programs. “This is not a budget. This is a cause,” he said. “The social safety net is fraying at the seams.” Chip Kahn, president of the Federation of American Hospitals, said that Ryan’s proposal would “result in the loss of health coverage for millions of low-income Americans, reduce critical benefits for others, and make it more difficult for hospitals, clinicians and other healthcare providers to deliver the care so many need.” Other critics maintain that Ryan’s approach will shift the higher costs to individuals, much as the change from defined-benefit pensions to 401(k) plans has increased retirement risk. Senior citizens, the disabled and the poor likely will pay more for healthcare, even as Washington pays less. Additionally, Ryan’s plan would permanently extend George W. Bush’s tax cuts.

“The idealized notion that older consumers would be making these annual choices may have some merit as an idea, but it doesn’t seem to be taking place in practice,” said Patricia Neuman, director of the Medicare Policy Project at the non-partisan Kaiser Family Foundation. Picking the right health plan could become even more critical if premiums outpace federal subsidies. In 2010, 50 percent of the nation’s Medicare recipients reported incomes of less than $21,000 a year, according to a Kaiser Family Foundation analysis.

In an opinion piece in the Seattle Post-Intelligencer, the “Monday Morning Economist” Stephen Herrington writes “The tax cut proposal is not getting the attention it deserves. If it shapes up to be anything like was described in Ryan’s Road Map, it will create massive dislocations and disruptions in the economy. Ryan’s plan was/is to cut the top tax bracket from 35 percent to 25 percent with the promise/expectation that this would not impact revenues. In a departure from the standard ‘trickle down’ excuse for tax cuts, Ryan meant/means to offset the admitted loss in revenues by eliminating all manner of deductions. The deductions in our current tax code, such as medical, mortgage and state income tax expense are there for a purpose. Eliminating them will introduce wild distortions in markets and effectively push the tax cuts for the rich onto the other 98 percent of us. Elimination of the medical expense deduction will intensify the impact of the Medicare/Medicaid part of the plan. It is as if Ryan thinks the magic of the free market can absorb any shock in real time. No more mortgage deduction? No problem, I just won’t buy a house at all until the lack of the mortgage deduction causes prices to fall by half.”

With the power shift in the House of Representatives, Medicare, Medicaid and Social Security are being targeted in proposed budget cuts designed to bring down the deficit. “It will likely be the first time you see a House have a prescription for Social Security, Medicare and Medicaid,” House Majority Leader Eric Cantor (R-VA) said at the Federation of American Hospitals’ annual public policy conference and business exposition in Washington.

Mississippi Governor Haley Barbour, a Republican, said that members of Mississippi’s Medicaid program saw its enrollment drop approximately 23 percent to 580,000 beneficiaries from 750,000 after the state started requiring beneficiaries to establish their eligibility in person. Barbour began this practice in his first year as governor in 2004. Senator Orrin Hatch (R-UT), the ranking Republican on the Senate Finance Committee, slammed the Patient Protection and Affordable Care Act (ACA), noting that its expansion of Medicaid will “bankrupt” the states, which already have strained budgets. Hatch also cited Congressional Budget Office figures that say the ACA’s Medicaid expansion will cost taxpayers $435 billion over the next decade.

President Barack Obama said his proposed 2012 budget was a “down payment,” on cutting the federal budget deficit, and said that more work is needed to address “long term challenges”. Cantor said that on “individual items” there were “probably some areas of agreement” between the President and Republicans. “But we can’t keep taking the savings and going to spend it,” he said. “The object here is to cut.” According to Cantor, the President’s plan “just misses the mark of living up to the expectations” Obama laid out in his State of the Union speech in January. Asked if Cantor expected adjustments to Social Security and Medicare, Cantor said he was “hopeful that we can get some cooperation from [Senate Majority Leader] Harry Reid [D-NV] and the President, because these are programs that touch the lives of every American and we don’t want, nor can we, make these changes by ourselves.”

Writing on the Huffington Post, Richard Eskow took an alarmist tone, saying that “entitlement reform” is a euphemism for allowing the elderly to die if they become ill. “’The President’s budget punts on entitlement reform,’ reads a statement by House Republicans. ‘Our budget will lead where the President has failed, and it will include realentitlement reforms.’ ‘You have to do entitlement reforms if you are serious about this budget,’ according to Representative Paul Ryan (R-WI).” Eskow counters “Reality check: Nobody’s proposing‘entitlement reform.’ That term is a cloaking device for some very ugly intentions. It’s a meaningless manufactured phrase cooked up by some highly-paid consultant, and it diminishes the sum total of human understanding every time it’s used. The phrase is a euphemism for deep cuts to programs that are vital and even life-saving for millions of elderly and poor people, but it’s politically unpalatable to say that. So it became necessary to come up with yet another cognition-killing term designed to numb us from the human toll of our political actions. ‘Entitlement reform’ is the new ‘collateral damage.’”

The Washington Post’s Ezra Klein is more diplomatic in his assessment of the possibility of entitlement reform. “We’ll see. I wouldn’t be surprised if Obama has his name on a broader deficit-reduction bill at this time next year. If he takes the deficit away from Republicans before 2012, his reelection campaign becomes considerably easier. And on a less cynical level, his administration is stocked with deficit hawks — the same folks who actually balanced the budget under Bill Clinton. And similarly, Republicans want to deliver on the deficit-reduction promises they’ve made to their base. In theory, everyone’s incentives and ideologies are pointing in the same direction. That’s a good sign for progress.”

Nurse burn-out – a result of working in high-stress environments – is bad for patient care and expensive for hospitals. According to the American Organization of Nurse Executives (AONE), “a conservative estimate” of the price of hiring a new nurse totals $10,000 in direct recruitment costs. In a hospital with 400 RNs on staff, it is no stretch to theorize that as many as 80 new nurses must be recruited and trained every year, adding up to $800,000 annually – and that’s just the direct costs.

These direct costs – which include recruiting a new nurse, hiring the optimal candidate and training that individual — represent only a small portion of the expense of hiring and training a nurse. It is the hidden costs – such as signing bonuses and other incentives, lost productivity because of the vacant position, and the expenses associated with training – that drive up the price of replacing RNs. Additionally, hospitals pay more to hire agency nurses versus employing nurses directly on their staff. A survey of hospital CEOs found that “agency nurses are often not familiar with policies, protocols and standards, and staff nurses then find that they have the additional burden of trying to educate these nurses on the unit.”

According to AONE estimates, the real cost of replacing a medical/surgical nurse is $42,000 and $64,000 for a specialty nurse. Kaiser Permanente places an even higher price tag on nurse turnover — $47,403 for a medical/surgical nurse and $85,197 for a specialty nurse. For the hypothetical 400-nurse hospital, the cost of replacing just 80 nurses annually could total $4 million in direct and hidden costs. Nationally, it is estimated that 1.3 million RNs are employed by hospitals. With an average turnover rate of approximately 15 percent, that translates to 195,000 nurse positions turning over every year at an estimated total cost of $9.75 billion.

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